Subtitles and Transcript

Vikram Patel

0:11
I want you to imagine this for a moment.Two men, Rahul and Rajiv,living in the same neighborhood,from the same educational background, similar occupation,and they both turn up at their local accident emergencycomplaining of acute chest pain.Rahul is offered a cardiac procedure,but Rajiv is sent home.

0:33
What might explain the difference in the experienceof these two nearly identical men?Rajiv suffers from a mental illness.The difference in the quality of medical carereceived by people with mental illness is one of the reasonswhy they live shorter livesthan people without mental illness.Even in the best-resourced countries in the world,this life expectancy gap is as much as 20 years.In the developing countries of the world, this gapis even larger.

1:04
But of course, mental illnesses can kill in more direct waysas well. The most obvious example is suicide.It might surprise some of you here, as it did me,when I discovered that suicide is at the top of the listof the leading causes of death in young peoplein all countries in the world,including the poorest countries of the world.

1:23
But beyond the impact of a health conditionon life expectancy, we're also concernedabout the quality of life lived.Now, in order for us to examine the overall impactof a health condition both on life expectancyas well as on the quality of life lived, we need to usea metric called the DALY,which stands for a Disability-Adjusted Life Year.Now when we do that, we discover some startling thingsabout mental illness from a global perspective.We discover that, for example, mental illnesses areamongst the leading causes of disability around the world.Depression, for example, is the third-leading causeof disability, alongside conditions such asdiarrhea and pneumonia in children.When you put all the mental illnesses together,they account for roughly 15 percentof the total global burden of disease.Indeed, mental illnesses are also very damagingto people's lives, but beyond just the burden of disease,let us consider the absolute numbers.The World Health Organization estimatesthat there are nearly four to five hundred million peopleliving on our tiny planetwho are affected by a mental illness.Now some of you herelook a bit astonished by that number,but consider for a moment the incredible diversityof mental illnesses, from autism and intellectual disabilityin childhood, through to depression and anxiety,substance misuse and psychosis in adulthood,all the way through to dementia in old age,and I'm pretty sure that each and every one uspresent here today can think of at least one person,at least one person, who's affected by mental illnessin our most intimate social networks.I see some nodding heads there.

3:10
But beyond the staggering numbers,what's truly important from a global health point of view,what's truly worrying from a global health point of view,is that the vast majority of these affected individualsdo not receive the carethat we know can transform their lives, and remember,we do have robust evidence that a range of interventions,medicines, psychological interventions,and social interventions, can make a vast difference.And yet, even in the best-resourced countries,for example here in Europe, roughly 50 percentof affected people don't receive these interventions.In the sorts of countries I work in,that so-called treatment gapapproaches an astonishing 90 percent.It isn't surprising, then, that if you should speakto anyone affected by a mental illness,the chances are that you will hear storiesof hidden suffering, shame and discriminationin nearly every sector of their lives.But perhaps most heartbreaking of allare the stories of the abuseof even the most basic human rights,such as the young woman shown in this image herethat are played out every day,sadly, even in the very institutions that were built to carefor people with mental illnesses, the mental hospitals.

4:29
It's this injustice that has really driven my missionto try to do a little bit to transform the livesof people affected by mental illness, and a particularlycritical action that I focused on is to bridge the gulfbetween the knowledge we have that can transform lives,the knowledge of effective treatments, and how we actuallyuse that knowledge in the everyday world.And an especially important challenge that I've had to faceis the great shortage of mental health professionals,such as psychiatrists and psychologists,particularly in the developing world.

5:00
Now I trained in medicine in India, and after thatI chose psychiatry as my specialty, much to the dismayof my mother and all my family members whokind of thought neurosurgery would bea more respectable option for their brilliant son.Any case, I went on, I soldiered on with psychiatry,and found myself training in Britain in some ofthe best hospitals in this country. I was very privileged.I worked in a team of incredibly talented, compassionate,but most importantly, highly trained, specializedmental health professionals.

5:30
Soon after my training, I found myself workingfirst in Zimbabwe and then in India, and I was confrontedby an altogether new reality.This was a reality of a world in which there were almost nomental health professionals at all.In Zimbabwe, for example, there were just abouta dozen psychiatrists, most of whom lived and workedin Harare city, leaving only a coupleto address the mental health care needsof nine million people living in the countryside.

5:56
In India, I found the situation was not a lot better.To give you a perspective, if I had to translatethe proportion of psychiatrists in the populationthat one might see in Britain to India,one might expect roughly 150,000 psychiatrists in India.In reality, take a guess.The actual number is about 3,000,about two percent of that number.

6:20
It became quickly apparent to me that I couldn't followthe sorts of mental health care models that I had been trained in,one that relied heavily on specialized, expensivemental health professionals to provide mental health carein countries like India and Zimbabwe.I had to think out of the box about some other modelof care.

6:38
It was then that I came across these books,and in these books I discovered the idea of task shiftingin global health.The idea is actually quite simple. The idea is,when you're short of specialized health care professionals,use whoever is available in the community,train them to provide a range of health care interventions,and in these books I read inspiring examples,for example of how ordinary people had been trainedto deliver babies,diagnose and treat early pneumonia, to great effect.And it struck me that if you could train ordinary peopleto deliver such complex health care interventions,then perhaps they could also do the samewith mental health care.

7:18
Well today, I'm very pleased to report to youthat there have been many experiments in task shiftingin mental health care across the developing worldover the past decade, and I want to share with youthe findings of three particular such experiments,all three of which focused on depression,the most common of all mental illnesses.In rural Uganda, Paul Bolton and his colleagues,using villagers, demonstrated that they could deliverinterpersonal psychotherapy for depressionand, using a randomized control design,showed that 90 percent of the people receivingthis intervention recovered as comparedto roughly 40 percent in the comparison villages.Similarly, using a randomized control trial in rural Pakistan,Atif Rahman and his colleagues showedthat lady health visitors, who are community maternalhealth workers in Pakistan's health care system,could deliver cognitive behavior therapy for motherswho were depressed, again showing dramatic differencesin the recovery rates. Roughly 75 percent of mothersrecovered as compared to about 45 percentin the comparison villages.And in my own trial in Goa, in India, we again showedthat lay counselors drawn from local communitiescould be trained to deliver psychosocial interventionsfor depression, anxiety, leading to 70 percentrecovery rates as compared to 50 percentin the comparison primary health centers.

8:36
Now, if I had to draw together all these differentexperiments in task shifting, and there have of coursebeen many other examples, and try and identifywhat are the key lessons we can learn that makesfor a successful task shifting operation,I have coined this particular acronym, SUNDAR.What SUNDAR stands for, in Hindi, is "attractive."It seems to me that there are five key lessonsthat I've shown on this slide that are critically importantfor effective task shifting.The first is that we need to simplify the messagethat we're using, stripping away all the jargonthat medicine has invented around itself.We need to unpack complex health care interventionsinto smaller components that can be more easilytransferred to less-trained individuals.We need to deliver health care, not in large institutions,but close to people's homes, and we need to deliverhealth care using whoever is available and affordablein our local communities.And importantly, we need to reallocate the few specialistswho are available to perform rolessuch as capacity-building and supervision.

9:38
Now for me, task shifting is an ideawith truly global significance,because even though it has arisen out of thesituation of the lack of resources that you findin developing countries, I think it has a lot of significancefor better-resourced countries as well. Why is that?Well, in part, because health care in the developed world,the health care costs in the [developed] world,are rapidly spiraling out of control, and a huge chunkof those costs are human resource costs.But equally important is because health care has becomeso incredibly professionalized that it's become very remoteand removed from local communities.For me, what's truly sundar about the idea of task shifting,though, isn't that it simply makes health caremore accessible and affordable but thatit is also fundamentally empowering.It empowers ordinary people to be more effectivein caring for the health of others in their community,and in doing so, to become better guardiansof their own health. Indeed, for me, task shiftingis the ultimate example of the democratizationof medical knowledge, and therefore, medical power.

10:47
Just over 30 years ago, the nations of the world assembledat Alma-Ata and made this iconic declaration.Well, I think all of you can guessthat 12 years on, we're still nowhere near that goal.Still, today, armed with that knowledgethat ordinary people in the communitycan be trained and, with sufficient supervision and support,can deliver a range of health care interventions effectively,perhaps that promise is within reach now.Indeed, to implement the slogan of Health for All,we will need to involve allin that particular journey,and in the case of mental health, in particular we wouldneed to involve people who are affected by mental illnessand their caregivers.

11:28
It is for this reason that, some years ago,the Movement for Global Mental Health was foundedas a sort of a virtual platform upon which professionalslike myself and people affected by mental illnesscould stand together, shoulder-to-shoulder,and advocate for the rights of people with mental illnessto receive the care that we know can transform their lives,and to live a life with dignity.

11:51
And in closing, when you have a moment of peace or quietin these very busy few days or perhaps afterwards,spare a thought for that person you thought aboutwho has a mental illness, or persons that you thought aboutwho have mental illness,and dare to care for them. Thank you. (Applause)(Applause)